Aortic dissection
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
suspected aortic dissection: haemodynamically unstable
1st line – advanced life support with haemodynamic support
advanced life support with haemodynamic support
Give supplemental oxygen and haemodynamic support.
Monitor controlled oxygen therapy. An upper SpO2 limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.
Evidence suggests that liberal use of supplemental oxygen (target SpO 2 >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[41]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. https://www.doi.org/10.1016/S0140-6736(18)30479-3 http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com
A lower target SpO 2 of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[42]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-ii90. https://www.doi.org/10.1136/thoraxjnl-2016-209729 http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Give intravenous fluid resuscitation and consider inotropes, particularly if the patient has incipient renal failure and hypovolaemic shock. See Acute kidney injury and Shock.
Check your local protocols for fluid choice and inotrope dose and choice. There is debate, based on conflicting evidence, on whether there is a benefit in using normal saline or balanced crystalloid in critically ill patients.
Practical tip
Be aware that large volumes of normal saline as the sole fluid for resuscitation may lead to hyperchloraemic acidosis.
Also note that use of lactate-containing fluid in a patient with impaired liver metabolism may lead to a spuriously elevated lactate level, so results need to be interpreted with other markers of volume status.
opioid analgesia
Treatment recommended for ALL patients in selected patient group
Ensure adequate pain relief using intravenous opioids to decrease sympathetic tone and facilitate haemodynamic stability.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com Be aware that morphine causes vasodilation and reduces the heart rate by increasing vagal tone.
Primary options
morphine sulfate: 2.5 to 10 mg intravenously initially, followed by 2.5 to 10 mg if required (at a rate of 1-2 mg/minute)
These drug options and doses relate to a patient with no comorbidities.
Primary options
morphine sulfate: 2.5 to 10 mg intravenously initially, followed by 2.5 to 10 mg if required (at a rate of 1-2 mg/minute)
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
morphine sulfate
confirmed type A aortic dissection
1st line – beta-blocker or non-dihydropyridine calcium-channel blocker
beta-blocker or non-dihydropyridine calcium-channel blocker
A type A dissection involves the ascending aorta with or without involvement of the arch and descending aorta.
Give medical therapy, while monitoring the patient’s vital signs closely.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com The aim of medical therapy is to decrease wall stress in order to limit the extension of the dissection and reduce the risk of developing end-organ damage and rupture.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com
If aortic regurgitation is excluded, give an intravenous beta-blocker (e.g., labetalol, metoprolol) to achieve:[14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Heart rate <60 beats per minute
Systolic blood pressure 100-120 mmHg.
If a beta-blocker is not suitable for the patient, a non-dihydropyridine calcium-channel blocker (i.e., verapamil or diltiazem) is an alternative.[18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Primary options
labetalol: 50 mg intravenously initially, followed by 50 mg every 5 minutes if required, maximum 200 mg/course; 2 mg/minute intravenous infusion until response then discontinue, usual dose 50-200 mg/course
OR
metoprolol: 2.5 to 5 mg intravenously initially (at a rate of 1-2 mg/minute), may repeat every 5 minutes if required, maximum 10-15 mg/total dose
Secondary options
diltiazem: consult specialist for guidance on dose
OR
verapamil: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
labetalol: 50 mg intravenously initially, followed by 50 mg every 5 minutes if required, maximum 200 mg/course; 2 mg/minute intravenous infusion until response then discontinue, usual dose 50-200 mg/course
OR
metoprolol: 2.5 to 5 mg intravenously initially (at a rate of 1-2 mg/minute), may repeat every 5 minutes if required, maximum 10-15 mg/total dose
Secondary options
diltiazem: consult specialist for guidance on dose
OR
verapamil: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
labetalol
OR
metoprolol
Secondary options
diltiazem
OR
verapamil
opioid analgesia
Treatment recommended for ALL patients in selected patient group
Ensure adequate pain relief using intravenous opioids to decrease sympathetic tone and facilitate haemodynamic stability.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com Be aware that morphine causes vasodilation and reduces the heart rate by increasing vagal tone.
Primary options
morphine sulfate: 2.5 to 10 mg intravenously initially, followed by 2.5 to 10 mg if required (at a rate of 1-2 mg/minute)
These drug options and doses relate to a patient with no comorbidities.
Primary options
morphine sulfate: 2.5 to 10 mg intravenously initially, followed by 2.5 to 10 mg if required (at a rate of 1-2 mg/minute)
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
morphine sulfate
vasodilator
Additional treatment recommended for SOME patients in selected patient group
Add vasodilator therapy (e.g., sodium nitroprusside) if the patient’s heart rate and systolic blood pressure are not adequately controlled with a beta-blocker (or a calcium-channel blocker) and analgesia.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Primary options
sodium nitroprusside: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
sodium nitroprusside: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
sodium nitroprusside
open surgery or endovascular repair
Treatment recommended for ALL patients in selected patient group
Immediately refer the patient for emergency surgery if they have a type A dissection.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com The mortality rate of patients receiving medical management alone for acute type A aortic dissection is two to three times that of those treated with surgical intervention.[30]Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000 Feb 16;283(7):897-903. http://jamanetwork.com/journals/jama/fullarticle/192401 http://www.ncbi.nlm.nih.gov/pubmed/10685714?tool=bestpractice.com
Depending on the extent of retrograde extension, the aortic valve may or may not need to be repaired or replaced.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com This is in order to prevent cardiac tamponade or fatal exsanguination from aortic rupture.
Therapeutic options include:[14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com
Open aortic arch replacement
Transposition of supra-aortic branches with subsequent endovascular repair
Total endovascular repair
The frozen elephant trunk repair technique, which combines open repair of the proximal aorta under deep hypothermic circulatory arrest, together with placement of thoracic stent grafts into the distal aortic arch and upper descending thoracic aorta. Of note, stent grafts designed for total endovascular aortic arch repair are currently only available as part of a clinical trial, and thus the use of this approach using off-the-shelf stent graphs is off-label.
confirmed type B aortic dissection: complicated
1st line – beta-blocker or non-dihydropyridine calcium-channel blocker
beta-blocker or non-dihydropyridine calcium-channel blocker
Type B dissection involves only the descending thoracic aorta (distal to the left subclavian artery) and/or abdominal aorta. Complications of type B dissection include:[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Signs of rupture (haemothorax, increasing periaortic or mediastinal haematoma) and/or hypotension or shock
Malperfusion (visceral, renal, limb, or spinal)
Early or rapid aortic expansion
Periaortic haematoma
Hypertension not controlled despite full medication
Persistent or recurrent pain.
Give medical therapy, while monitoring the patient’s vital signs closely.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com The aim of medical therapy is to decrease wall stress in order to limit the extension of the dissection and reduce the risk of developing end-organ damage and rupture.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com
If aortic regurgitation is excluded, give an intravenous beta-blocker (e.g., labetalol, metoprolol) to achieve:[14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Heart rate <60 beats per minute
Systolic blood pressure 100-120 mmHg.
If a beta-blocker is not suitable for the patient, a non-dihydropyridine calcium-channel blocker (i.e., verapamil or diltiazem) is an alternative.[18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Primary options
labetalol: 50 mg intravenously initially, followed by 50 mg every 5 minutes if required, maximum 200 mg/course; 2 mg/minute intravenous infusion until response then discontinue, usual dose 50-200 mg/course
OR
metoprolol: 2.5 to 5 mg intravenously initially (at a rate of 1-2 mg/minute), may repeat every 5 minutes if required, maximum 10-15 mg/total dose
Secondary options
diltiazem: consult specialist for guidance on dose
OR
verapamil: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
labetalol: 50 mg intravenously initially, followed by 50 mg every 5 minutes if required, maximum 200 mg/course; 2 mg/minute intravenous infusion until response then discontinue, usual dose 50-200 mg/course
OR
metoprolol: 2.5 to 5 mg intravenously initially (at a rate of 1-2 mg/minute), may repeat every 5 minutes if required, maximum 10-15 mg/total dose
Secondary options
diltiazem: consult specialist for guidance on dose
OR
verapamil: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
labetalol
OR
metoprolol
Secondary options
diltiazem
OR
verapamil
opioid analgesia
Treatment recommended for ALL patients in selected patient group
Ensure adequate pain relief using intravenous opioids to decrease sympathetic tone and facilitate haemodynamic stability.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com Be aware that morphine causes vasodilation and reduces the heart rate by increasing vagal tone.
Primary options
morphine sulfate: 2.5 to 10 mg intravenously initially, followed by 2.5 to 10 mg if required (at a rate of 1-2 mg/minute)
These drug options and doses relate to a patient with no comorbidities.
Primary options
morphine sulfate: 2.5 to 10 mg intravenously initially, followed by 2.5 to 10 mg if required (at a rate of 1-2 mg/minute)
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
morphine sulfate
vasodilator
Additional treatment recommended for SOME patients in selected patient group
Add vasodilator therapy (e.g., sodium nitroprusside) if the patient’s heart rate and systolic blood pressure are not adequately controlled with a beta-blocker (or a calcium-channel blocker) and analgesia.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Primary options
sodium nitroprusside: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
sodium nitroprusside: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
sodium nitroprusside
endovascular repair or open surgery
Treatment recommended for ALL patients in selected patient group
Urgently refer the patient for thoracic endovascular aortic repair (TEVAR) or open surgery if they have a type B dissection that is complicated by:[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Signs of rupture (haemothorax, increasing periaortic or mediastinal haematoma) and/or hypotension or shock
Malperfusion (visceral, renal, limb, or spinal)
Early or rapid aortic expansion
Periaortic haematoma
Hypertension not controlled despite full medication
Persistent or recurrent pain.
TEVAR is the treatment of choice for most patients.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com However, open surgery may be indicated if the patient has:[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com
Arterial disease of the lower extremities
Severe tortuosity of the iliac arteries
A sharp angulation of the aortic arch
Absence of a proximal landing zone for the stent graft.
confirmed type B aortic dissection: uncomplicated
1st line – beta-blocker or non-dihydropyridine calcium-channel blocker
beta-blocker or non-dihydropyridine calcium-channel blocker
Type B dissection involves only the descending thoracic aorta (distal to the left subclavian artery) and/or abdominal aorta. Medical management with intensive monitoring alone may be sufficient for these patients if they do not have any of the following complications:[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Signs of rupture (haemothorax, increasing periaortic or mediastinal haematoma) and/or hypotension or shock
Malperfusion (visceral, renal, limb, or spinal)
Early or rapid aortic expansion
Periaortic haematoma
Hypertension not controlled despite full medication
Persistent or recurrent pain.
Give medical therapy, while monitoring the patient’s vital signs closely.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com The aim of medical therapy is to decrease wall stress in order to limit the extension of the dissection and reduce the risk of developing end-organ damage and rupture.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com
If aortic regurgitation is excluded, give an intravenous beta-blocker (e.g., labetalol, metoprolol) to achieve:[14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Heart rate <60 beats per minute
Systolic blood pressure 100-120 mmHg.
If a beta-blocker is not suitable for the patient, a non-dihydropyridine calcium-channel blocker (i.e., verapamil or diltiazem) is an alternative.[18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Primary options
labetalol: 50 mg intravenously initially, followed by 50 mg every 5 minutes if required, maximum 200 mg/course; 2 mg/minute intravenous infusion until response then discontinue, usual dose 50-200 mg/course
OR
metoprolol: 2.5 to 5 mg intravenously initially (at a rate of 1-2 mg/minute), may repeat every 5 minutes if required, maximum 10-15 mg/total dose
Secondary options
diltiazem: consult specialist for guidance on dose
OR
verapamil: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
labetalol: 50 mg intravenously initially, followed by 50 mg every 5 minutes if required, maximum 200 mg/course; 2 mg/minute intravenous infusion until response then discontinue, usual dose 50-200 mg/course
OR
metoprolol: 2.5 to 5 mg intravenously initially (at a rate of 1-2 mg/minute), may repeat every 5 minutes if required, maximum 10-15 mg/total dose
Secondary options
diltiazem: consult specialist for guidance on dose
OR
verapamil: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
labetalol
OR
metoprolol
Secondary options
diltiazem
OR
verapamil
opioid analgesia
Treatment recommended for ALL patients in selected patient group
Ensure adequate pain relief using intravenous opioids to decrease sympathetic tone and facilitate haemodynamic stability.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com Be aware that morphine causes vasodilation and reduces the heart rate by increasing vagal tone.
Primary options
morphine sulfate: 2.5 to 10 mg intravenously initially, followed by 2.5 to 10 mg if required (at a rate of 1-2 mg/minute)
These drug options and doses relate to a patient with no comorbidities.
Primary options
morphine sulfate: 2.5 to 10 mg intravenously initially, followed by 2.5 to 10 mg if required (at a rate of 1-2 mg/minute)
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
morphine sulfate
vasodilator
Additional treatment recommended for SOME patients in selected patient group
Add vasodilator therapy (e.g., sodium nitroprusside) if the patient’s heart rate and systolic blood pressure are not adequately controlled with a beta-blocker (or a calcium-channel blocker) and analgesia.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Primary options
sodium nitroprusside: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
sodium nitroprusside: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
sodium nitroprusside
endovascular repair
Additional treatment recommended for SOME patients in selected patient group
Thoracic endovascular aortic repair (TEVAR) may be considered in some patients with uncomplicated type B dissection, including those with features that indicate they are at high risk of developing complications, such as bloody pleural effusion, aortic diameter >40 mm, and malperfusion that is only detectable on imaging.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [3]Lombardi JV, Hughes GC, Appoo JJ, et al. Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections. J Vasc Surg. 2020 Mar;71(3):723-47. http://www.ncbi.nlm.nih.gov/pubmed/32001058?tool=bestpractice.com [14]Czerny M, Schmidli J, Adler S, et al. Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2019 Feb;57(2):165-98. https://www.doi.org/10.1016/j.ejvs.2018.09.016 http://www.ncbi.nlm.nih.gov/pubmed/30318395?tool=bestpractice.com If TEVAR is indicated, it is performed in the subacute phase (14 days to 6 weeks after the onset of symptoms) to promote false lumen thrombosis and prevent aneurysmal degeneration.
chronic aortic dissection
beta-blocker
Aortic dissection is a lifelong condition and is defined as chronic at >90 days since the first onset of symptoms.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [5]Fleischmann D, Afifi RO, Casanegra AI, et al. Imaging and surveillance of chronic aortic dissection: a scientific statement from the American Heart Association. Circ Cardiovasc Imaging. 2022 Mar;15(3):e000075. https://www.ahajournals.org/doi/full/10.1161/HCI.0000000000000075?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/35172599?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com This includes patients with type A dissection with persisting dissection of the descending aorta following surgical repair of the aortic arch.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com
The patient may also be diagnosed with chronic dissection if the first diagnosis of aortic dissection is picked up as an incidental finding at the chronic stage (e.g., an incidental finding of mediastinal widening or prominent aortic knob on chest x-ray).[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com
The largest group of patients with chronic aortic dissection (approximately ≈60%) are those with surgically corrected ascending (Stanford type A) dissection with a persistent false lumen distal to the surgical repair.[5]Fleischmann D, Afifi RO, Casanegra AI, et al. Imaging and surveillance of chronic aortic dissection: a scientific statement from the American Heart Association. Circ Cardiovasc Imaging. 2022 Mar;15(3):e000075. https://www.ahajournals.org/doi/full/10.1161/HCI.0000000000000075?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/35172599?tool=bestpractice.com Patients with non-operated type A dissection rarely live past the acute event; hence, chronic dissections of the ascending aorta are exceedingly rare.[5]Fleischmann D, Afifi RO, Casanegra AI, et al. Imaging and surveillance of chronic aortic dissection: a scientific statement from the American Heart Association. Circ Cardiovasc Imaging. 2022 Mar;15(3):e000075. https://www.ahajournals.org/doi/full/10.1161/HCI.0000000000000075?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/35172599?tool=bestpractice.com
Manage patients with chronic aortic dissection in line with the same medical principles employed in the acute phase. Manage the patient’s blood pressure and heart rate very carefully.
Aim for a target blood pressure of <120/80 mmHg and a heart rate <60 beats per minute.[18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Use a long-acting beta-blocker (e.g., bisoprolol) as a first-line treatment.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Primary options
bisoprolol: 5-10 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day
additional antihypertensive therapy
Additional treatment recommended for SOME patients in selected patient group
Most patients will require at least two antihypertensives. Additional drugs include an angiotensin-II receptor antagonist (e.g., losartan) or ACE inhibitor (e.g., enalapril) second line, and a calcium-channel blocker (e.g., nifedipine) third line.[18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com A thiazide-like diuretic (e.g., indapamide) may also be used.[67]National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Nov 2023 [internet publication]. https://www.nice.org.uk/guidance/ng136
Examples of options are detailed here. Combination therapy may be required in some circumstances.
Primary options
losartan: 18-75 years of age: 50 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day; ≥76 years of age: 25 mg orally once daily initially, increase gradually according to response, maximum 100 mg/day
OR
enalapril: 5 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
OR
nifedipine: 10 mg orally (modified-release/sustained-release) twice daily initially, increase gradually according to response, maximum 80 mg/day; 30 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90 mg/day
OR
indapamide: 2.5 mg orally (immediate-release) once daily in the morning; 1.5 mg orally (modified-release) once daily in the morning
lifestyle advice
Treatment recommended for ALL patients in selected patient group
Advise the patient to avoid contact sports and strenuous physical activities (such as isometric heavy weight lifting, pushing, or straining that would require a Valsalva manoeuvre) to reduce aortic wall shear stress due to sudden rises in arterial blood pressure during exercise.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
However, activities with low static and dynamic stress (mild aerobic exercise and daily activities) can be continued.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com [18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
The patient should also avoid cocaine or other stimulating drugs such as methamphetamine.[18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
risk factor management
Treatment recommended for ALL patients in selected patient group
Manage risk factors for atherosclerotic disease; in particular, advise:[18]Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: diagnosis and management, an update. Eur Heart J. 2018 Mar 1;39(9):739-49d. https://www.doi.org/10.1093/eurheartj/ehx319 http://www.ncbi.nlm.nih.gov/pubmed/29106452?tool=bestpractice.com
Smoking cessation
Lipid-lowering therapy (target of LDL-cholesterol <70 mg/dL - see Hypercholesterolaemia for more information).
endovascular repair or open surgery
Additional treatment recommended for SOME patients in selected patient group
Ensure the patient has close surveillance and follow-up to monitor for complications.[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com See Monitoring section.
Organise thoracic endovascular aortic repair (TEVAR) or surgery if the patient has a chronic type B dissection and develops any of the following complications:[2]Erbel R, Aboyans V, Boileau C, et al; ESC Committee for Practice Guidelines. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J. 2014 Nov 1;35(41):2873-926. https://academic.oup.com/eurheartj/article/35/41/2873/407693/2014-ESC-Guidelines-on-the-diagnosis-and-treatment http://www.ncbi.nlm.nih.gov/pubmed/25173340?tool=bestpractice.com
Rupture
Chronic visceral or limb malperfusion
Progressive aneurysmal enlargement (growth of >10 mm/year)
False lumen aneurysms (with total aortic diameter >60 mm)
Persistent or recurrent pain.
Bear in mind that patients with connective tissue diseases and those with a family history of aortic dissection warrant more careful consideration and may be suitable for earlier intervention (diameter of 50-55 mm).[5]Fleischmann D, Afifi RO, Casanegra AI, et al. Imaging and surveillance of chronic aortic dissection: a scientific statement from the American Heart Association. Circ Cardiovasc Imaging. 2022 Mar;15(3):e000075. https://www.ahajournals.org/doi/full/10.1161/HCI.0000000000000075?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/35172599?tool=bestpractice.com [69]Coselli JS, LeMaire SA. Current status of thoracoabdominal aortic aneurysm repair in Marfan syndrome. J Card Surg. 1997 Mar-Apr;12(2 suppl):167-72. http://www.ncbi.nlm.nih.gov/pubmed/9271742?tool=bestpractice.com [70]LeMaire SA, Carter SA, Volguina IV, et al. Spectrum of aortic operations in 300 patients with confirmed or suspected Marfan syndrome. Ann Thorac Surg. 2006 Jun;81(6):2063-78. https://www.annalsthoracicsurgery.org/article/S0003-4975(06)00195-0/fulltext http://www.ncbi.nlm.nih.gov/pubmed/16731131?tool=bestpractice.com
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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